Archive for the ‘Force function’ Category

I have read much material lately about addressing the obesity epidemic and there are many commonalities in the latest theories.
1. Motivation- focusing on motivation as a strategy is not the best approach. Willpower has been dismissed by many as a poor approach to weight management
2. Behavior change- changing behaviors is not easy. Much of a person’s day consists of habitual activities resulting from cues from tv, peers, childhood… example wanting to eat popcorn while watching a movie, reaching for the salt before tasting food…
3. Environment changes-For obesity this holds the most promise. Its seen in weight watchers programs and Wansink’s book Slimdown by design. Change architecture and nudging can help make behavior change easier and lasting. This includes things like using smaller colorfull plates, moving healthy foods to a prominent kitchen spot and unhealthy foods to hidden cabinets. In some estimates people who follow certain environmental patterns are 18% thinner than those who do not.

What’s the correlation with patient safety?
1. Motivation- focusing on motivation as a strategy is not the best approach. Motivating staff to be more vigilant? Teaching them? Telling them to Follow rules and policies? These have not been shown to increase safety measurably. In fact sometimes recognizing when to deviate from rules can add resilience
2. Behavior change- changing behaviors is not easy. Other articles on this cite describe many nursing behaviors as being based on tradition and automatic behavior. Often under stress people revert back to old knowledge. How many times has an initiative been rolled out only to see it vanished from practice within a year?
3. Environment changes- just as in obesity management here we might find the most bang for our buck so to speak. Make it easy for staff to do the right thing. Make it hard for staff to do the wrong thing. Create systems that nudge staff toward safe behaviors. Use change architecture to produce reliability

A healthier world depends on reducing obesity and unsafe patient care. Maybe the solutions to both are the same.

“SSM Health Care acknowledged Tuesday that its neurosurgeon and medical staff recently operated on the wrong side of a St. Louis-area woman’s brain and skull.
The admission — and a lengthy public apology — followed a Post-Dispatch story in Tuesday’s paper about a lawsuit filed Friday on behalf of Regina Turner of St. Ann.
“SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room,” Chris Howard, president and chief executive of SSM Health Care-St. Louis, said in a written statement. As a result of the mistaken surgery on April 4, Turner, 53, now needs 24-hour nursing care for her basic needs and cannot speak intelligibly, said Alvin Wolff Jr., her Clayton-based attorney.
According to the lawsuit filed in circuit court in Clayton, the former paralegal “will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”“This was a breakdown in our procedures, and it absolutely should not have happened,” Howard wrote in his statement. “We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion. We immediately began an investigation.”

Time outs and checklists have reduced the incident of wrong side surgery but not eliminated the problem. Let’s analyze this from the human factors/risk management Hierarchy of Intervention Effectiveness (see graphic below). While checklists and standard time-outs are better than education, they do not reach the level of automation or force function.

In the words of Cafazzo & St-Cyr (2012,http://www.longwoods.com/content/22845)“Although checklist use has recently made headlines in its ability to reduce adverse events in settings such as the operating room and intensive care (Haynes et al. 2009; Pronovost 2006), it remains unclear that an intervention so fundamentally reliant on human behaviour will be sustainable in the long term without constant enforcement (Bosk et al. 2009). Are all healthcare organizations able to create a culture for the sustained use of checklists? If this solution applies only to organizations that have the leadership and resources to maintain such a culture, checklists – and other solutions reliant on human behaviour – cannot be considered a systemic solution. Given how rare serious adverse events are to the total volume of healthcare encounters, a solution that applies to only a fraction of organizations cannot address this safety issue fully.”

My thoughts: why can’t we ace wrap the WRONG side…with a distinctive sterile wrap designed like yellow police tape (DO NOT CROSS!).. it can be removed once the first cut is made into the appropriate surgical site.
Simple, but it would provide some force function as the team would literally have to remove a wrapping that said “WRONG SIDE” in order to make a mistake!
Graphic: Cafazzo and St-Cyr, 2012http://www.longwoods.com/content/22845
A safetydog: BEST.ARTICLE.EVER.

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RCA (root cause analysis) is a tool often used to provide an assessment after the occurrence of an adverse event or when investigating the safety of an environment. The idea behind this risk assessment is to uncover the overt and latent factors behind unsafe situations. In non-medical industries this has proven to be an effective tool but in healthcare, the belief that this tool helps is variable. While many RCAs have uncovered surprising holes in healthcare safety systems, there are also concerns with its value.

In a 2008 interview with Robert Watcher, Albert Wu said “Although we are living in an era of evidence-based medicine, root cause analysis was widely adopted by the medical community in the 1990s without the benefit of much evidence. Every institution now conducts root cause analysis. Thousands of health care workers devote many hours to conducting these analyses, yet root cause analysis has never really been evaluated.” (AHRQ, http://webmm.ahrq.gov/perspective.aspx?perspectiveID=61)

Innovative technology to provide for necessary monitoring of patient vital signs. For example, as the Wall Street Journal proclaimed in its story about Howard Snitzer “A little known device is shaking conventional wisdom for reviving people who suffer sudden cardiac arrest: People may be able to go much longer without a pulse than the 20 minutes previously believed.”

Health Care Providers who must make critical live-saving decisions, such as anesthesiologists who, as the American Society of Anesthesiologists says, “are responsible for administering anesthesia to relieve pain and for managing vital life functions, including breathing, heart rhythm and blood pressure, during surgery. After surgery, they maintain the patient in a comfortable state during the recovery and are involved in the provision of critical care medicine in the intensive care unit.”

Information on what works and how it enhances patient health and safety.”

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On this blog we have seen the analogy of swiss cheese to safety in the form of James Reason’s swiss cheese model of failure. Now what could cookies, as yummy as they are, possibly have to do with safety?

Yesterday, I walked up to the city marketplace after work to get a snack: Chipyard cookies were calling my name. As I approached the stand, I recalled a story from a colleague who was fired from this company in college. It seems after baking the cookies, the staff were required to take the hot trays from the oven and load them onto to a backing rack. The procedure would be to yell “hot tray” and then slide the tray onto the rack to cool. Several times, my colleague yelled “hot tray” and as she was placing the tray into the rack she would use a bit too much force and the tray would slide out the back of the rack through an open window panel! The “hot tray” of cookies would drop out onto the pavement behind the cookie stand rendering them unsellable.

She was shown the “safety” procedure several times yet somehow the cookies kept ending up on the pavement. Thinking she hired a bad apple, the manager fired my colleague who is now an incredible nurse who saves kids’ lives…bad apple indeed.

When I walked up to the cookie stand last evening I noticed something amazing. They had built a small wall right behind the cooling rack! I asked the girl at the counter “Hey does anyone ever ruin the hot tray of cookies by knocking them through the rack?” She looked at me increduously! This new generation of workers could not even conceive of making an error of this type. This is forced function at its best and illustrates the effectiveness of this type of intervention over education and prompts to do better to eliminate safety hazards.

Do we have similar situations in healthcare? Are we telling staff over and over “Don’t make this mistake” “watch what you are doing!” “be more careful” or are we building barriers to unsafe actions and behaviors that will create and sustain safety for our patients?

I can think of one success in particular. Seasoned nurses will talk about the old days when they mixed chemotherapy in the kitchen on the inpatient units. New nurses will listen with horror as they only know chemotherapy that comes in specially prepared and labelled containers from the pharmacy.

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“In 2010, the federal government estimated that faulty medical care contributed to the death of about 15,000 Medicare patients per month. By these meas­ures, faulty hospital care is one of the leading causes of death, behind heart disease and cancer.

Why haven’t hospitals made more progress on patient safety? The reasons are multiple and complex, but they boil down to the fact that hospitals are hierarchical organizations resistant to change, they haven’t done enough to create environments in which patient safety is a priority, and they’ve been reluctant to share patient-safety data with the public.

Even getting full compliance on basic safety standards, such as washing hands, has proved elusive because hospitals are busy, high-stress places full of distractions.

“We are humans and are destined to make mistakes,” says Nancy Foster, vice president of quality and patient-safety policy at the 5,000-member American Hospital Association. “The question in health care is: Can we design processes and have them in place so when an individual makes a natural mistake, that mistake doesn’t result in harm to patients?”

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Let me begin 2012 by recommending that everyone subscribe to ISMPs safety newsletters: let that be your first New Year’s resolution in committing to make your practice safer. There is an acute care edition, ambulatory edition, nursing edition and consumer edition. Subscribe here.

The december nursing edition (Nurse-ERR) describes a case where an ADULT patient (not a pedi patient!) was found to have swallowed one of the small white caps that covers the end of a syringe. This was discovered after the patient developed a cough after discharge. After a particularly intense coughing episode, the cap came out! This patient had no recollection of swallowing this cap. The newsletter recounts historical dangers associated with small parts left at the bedside of patients and their subsequent inhalation. Of course this has always been a concern for pediatric patients but now we see the SAME RISK in adults.

Nurse ERR wisely recommends all staff scan patients’ rooms for potentially dangerous items left at the bedside and that this be added to rounding procedures by all disciplines: housekeeping, Nursing, MDs and even family and visitors. The more eyes the better.

In the spirit of this blog and its focus on human factors, I would also like to implore manufacturers of hospital products (especially IV related products with small caps and pull caps) to help eliminate these hazards alltogether by making caps that are NOT detachable. Make all removable small pieces removable but stay attached.

It can be done for usb ports…why not do it for something that can save a life?

I always lost these caps...

This design Prevents loss of the cap!

Even better! This design prevents loss of cap and actually encourages one to recap.

Update: I emailed the ISMP asking for their advocacy in getting manufacturers to develop products that force safety in their IV supply products..then I emailed Baxter requesting they develop a product. I got a call back and they were concerned about infection and recapping but responded that they would pass this onto their engineers to see if something could be done that would attach the cap yet protect the patient from potential infection by preventing recapping. Here’s hoping they can come up something so our only safety barrier isn’t front line staff vigilance. Thanks to both these agencies for being responsive.

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About this blog: You’ve heard of Leapfrog now there’s SafetyDog!

This blog will merge ideas from management, nursing, medicine and psychology (and many others) to offer a different view of patient safety. The author has a Masters in Industrial-Organizational Psychology, a graduate certificate in Error Science and Patient Safety and also a BSN in Nursing and has worked as an RN since 1985. All comments are welcome..you never know when one of your thoughts might save a life!

Patient Safety

IOM
Institute of Medicine..their 1999 report “To Err is human” started it all.

Leap Frog Group
The Consumer Reports for hospitals. Encouraging transparency and comparison of quality and safety.

ISMP
Institute for Safe Medication Practices. If you are looking for information on safe medication practices (and unsafe ones) they have great newsletters and other resources.

IHI
The Institute for Healthcare Improvement has an entire section on patient safety.

AHRQ
The Agency for Healthcare Research and Quality. Great site from the Department of Health and Human services. Contains research articles and safety guidelines and tools. The link is to Patient safety net

Healthcare Quarterly
Best practices and peer reviewed articles. Editor is a PhD from the University of North Carolina.